Provider Demographics
NPI:1417297821
Name:ST LUKES CLINIC-TREASURE VALLEY LLC
Entity Type:Organization
Organization Name:ST LUKES CLINIC-TREASURE VALLEY LLC
Other - Org Name:ST LUKES RHC - TRINITY MOUNTAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VP, CFO
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-381-8717
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83701-0640
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:465 MCKENNA DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-2143
Practice Address - Country:US
Practice Address - Phone:208-587-9703
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST LUKES REGIONAL MEDICAL CENTER LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-21
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID207Q00000X, 207R00000X, 208000000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1369110OtherMEDICARE / MULTI SPECIALTY CLINIC
ID133999OtherMEDICARE / RHC